Retroactive MC

An applicant for MC, CW, SSI/SSP, or RCA may be eligible to receive MC for any of the three (3) months immediately before the month of application. Any written request for retroactive coverage must be considered an application.

When adding an individual to an ongoing MC case the individual’s date of application is the date of request.

ExampleExampleAn active MC case exists with a mother, father and child with an original application date of 1/25/2014. The father is not requesting aid but he does live in the home. He requests MC coverage for himself on 10/13/2017, he is potentially eligible for Retroactive MC for the months of 09/2017, 08/2017 and 07/2017.

For SSI/SSP applicants, the application date is the same date as the Social Security Administration application date, even if SSI/SSP is never approved for the month of application. The application date can be obtained from the [SDX3] screen in MEDS.

For APTC recipients moving to MAGI in a Carry Forward Status (CFS), the Insurance Affordability Program (IAP) transition date will be considered the date of application.

Retroactive MC Request Time Limit

An application for retroactive MC must be submitted within 12 months from the month of service. If a request for retroactive MC is made for any of the 3 retroactive months more than 12 months from the date of service, then the retroactive MC request will be denied. When adding a person to an ongoing case the individual’s retroactive MC period is also from the date of service and the individual’s request date.

Example Example Mr. Cobblesworth applied for MC on 4/1/17. He had medical expenses in January, February and March of 2017, but did not apply for Retroactive MC because he thought his insurance would cover the cost. In February 2018, he discovers that his insurance did not pay and applies for Retro. In February 2018, he can be approved for MC for February and March 2017 but it is too late for January 2015. (Retro MC for January 2017 will be denied.)

Example Example An active MC case exists with a mother, father and child with an original application date of 1/25/2014. The father is not requesting aid but he does live in the home. He requests MC on 10/13/2017, he is potentially eligible for Retroactive MC for the months of 07/2017, 08/2017 and 09/2017. He has until 07/2018, 08/2018 and 09/2018, respectively to request Retroactive MC if he has medical bills in 07/2017, 08/2017 and/or 09/2017.

Eligibility Conditions

In order to be eligible for retroactive MC, all of the following conditions must be met in each retroactive month:

The applicant would have been eligible for MC had an application been filed.
The applicant received a health care service. (The applicant has medical bills.)
The applicant was not previously denied MC for the month in question unless the denial was due to:
- County error, or
- Circumstances beyond the applicant’s control.

Retroactive MC Applications

Eligibility for retroactive MC must always be explored at the point of intake and/or at any time an applicant makes a request. A person applying for retroactive MC must submit a MC 210 A. If the application is for retroactive MC coverage only, then an SSApp or any other acceptable MC application/SOF form must be submitted.

Note: For SSI/SSP applicants requesting Retroactive MC, EWs are to request only the MC 210 A, and information and documents that is not available through MEDS/SDX inquiry screens, and is necessary to determine eligibility. SSI/SSP applicants are not required to submit the SSApp, but an MC 210 A must still be submitted.

When an Intake EW receives an application (e.g. SAWS 2 Plus, etc.) which indicates the individual wants Retroactive MC, they must contact the individual to confirm the request. The confirmation must take place before the EW can request the application registration for Retroactive MC. The table below outlines the process for the Intake EW:

Exception: Many applications that come from Valley Medical Center (VMC) are for hospitalized individuals and often, additional attempts to contact the applicant may fail. The EW must still try to contact the applicant and document the outcome of the attempt (i.e. phoned or visited applicant but unable to confirm request for Retroactive MC due to applicant’s unavailability.) In these instances, the Retroactive MC application may be registered without confirmation.

If...	Then...
The client is reached and they clarify they do NOT need MC for any of the three months prior to the month of application	Clearly document in case comments that per conversation with the client, Retroactive MC is not being requested
The client is reached and they confirm they are requesting Retroactive MC and incurred medical bills for any of the three months prior to the month of application	Complete the MC 210 A with the client by phone and obtain a telephonic signature Submit the application registration request to Clerical for the required months of Retro MC Process the Retroactive MC If verification is required to disposition the Retroactive application, a request for verification should be sent to the client and the case must remain assigned to the Intake EW until the verification due date If MC 210 A is received but the client later verbally withdraws their request, case comment and send the SCD 166 to be completed and returned by the client
The client is NOT reached	Mail the MC 210 A to the client and allow a 10-day due date for the return. Clearly document in case comments that attempt to reach client by phone was made and the MC 210 A was mailed **Intake EW must hold the case until the 10-day due date and case comment before transferring it to continuing, OR if client responds before the due date, the Intake EW must disposition the case and case comment before transferring it to continuing

Important: Clerical staff must not complete the application registration for Retroactive MC until the Intake EW has requested it.

Requests for retroactive Medi-Cal can be approved in Santa Clara County regardless of residency during the month(s) of request. This will prevent the client from having to apply for ongoing MC in Santa Clara county and retroactive MC in their previous county of residence. Retroactive MC is fee for service so there is no impact to the clients coverage.

Retroactive MC for Mail-In Applications

Anyone requesting retroactive MC using the SSApp or any other acceptable MC application form must also complete the MC 210 A. The EW must send the MC 210 A when retroactive MC is requested. The EW may assist the client by completing the MC 210 A over the phone. A telephonic signature for the MC 210 A is acceptable.

Retroactive MC Based on Disability

This section only applies to clients who do not qualify under MAGI MC rules. Individuals applying on the basis of disability must have their disability determined prior to approval of retroactive benefits.

For SSI/SSP pending applications, a determination of MC under any other program must be made for the retroactive months.

The EW must: